Plantar Vein Thrombosis - Journal of the Belgian Society of Radiology

Vansevenant, M and Vanhoenacker, F M 2015 Plantar Vein Thrombosis: An Unusual Cause
of Plantar Pain. Journal of the Belgian Society of Radiology, 99(2), pp. 98–101, DOI: http://
dx.doi.org/10.5334/jbr-btr.874
CASE REPORT
Plantar Vein Thrombosis: An Unusual Cause of Plantar Pain
M. Vansevenant*,† and F. M. Vanhoenacker*,†,‡
We present a case of an 80-year-old man with progressive pain for 5 days at the medial and plantar
aspect of the left heel. Wearing shoes aggravated the pain. Ultrasound and magnetic resonance imaging
(MRI) revealed thrombosis of the medial plantar veins. Plantar vein thrombosis is a rare condition. The
clinical symptoms are non-specific and can be confused with plantar fasciitis. It has been associated with
hypercoagulable conditions, foot trauma and recent surgery. The imaging modality of choice is ultrasound.
MRI may add to the diagnosis in unclear cases.
Keywords: Plantar vein thrombosis; ultrasound; MRI
Introduction
Plantar heel pain is a very common complaint, accounting
for up to 11% to 15% of foot and ankle disorders. Most of
these patients with plantar heel pain suffer from plantar
fasciitis [1]. The purpose of this manuscript is to report a
rare cause of plantar heel pain resulting from plantar vein
thrombosis.
Case
An 80-year-old man with progressive pain lasting for
5 days and with focal swelling of the left foot was referred
to the radiology department. Wearing shoes aggravated
the pain. Inspection of his footwear showed a bump at the
inner sole, corresponding with the location of the clinical
abnormality at the heel of the patient. Clinically, there was
suspicion of plantar fasciitis.
Plain films showed the absence of inferior calcaneal spur
formation. Ultrasound revealed a normal plantar fascia.
Medially from the plantar fasciitis, adjacent to the course
of the medial plantar artery, hypoechoic tubular structures were seen, which were not compressible. There was
no intralesional flow on color Doppler imaging (Figure 1).
Comparison with the right foot showed normal compressible veins. Subsequent MRI confirmed thrombosis of the
medial plantar veins (Figure 2).
*Department of Radiology, AZ Sint-Maarten, Mechelen-Duffel,
Duffel, Belgium
milan.vansevenant@ugent.be
†Department of Radiology, Ghent University Hospital (UZ Gent),
Ghent, Belgium
‡Department of Radiology, Antwerp University Hospital (UZA),
Edegem, Belgium
filip.vanhoenacker@telenet.be
Corresponding author: Prof. Dr. F. M. Vanhoenacker
The symptoms disappeared after conservative therapy
with change of footwear and non-steroidal anti-inflammatory drugs. Follow-up ultrasound 2 months later revealed no
residual thrombus in the plantar veins.
Discussion
Plantar vein thrombosis has been considered a very rare
cause of plantar foot pain because the condition has been
reported rarely as cause of plantar pain [2–5]. However,
the frequency of the condition might be underestimated.
Most often, plantar heel pain is attributed to mechanical
problems, resulting in plantar fasciitis [1]. The symptoms
of plantar vein thrombosis are non-specific and include
plantar foot pain, local swelling [2–5] and pain increasing
during walking [4].
The deep plantar veins are divided in the lateral and
medial plantar veins, accompanying the lateral and
medial plantar artery. These two veins initiate at the first
intermetatarsal space. They are connected at this first
intermetatarsal space with the superficial venous system.
At the medial malleolus, they drain to the posterior tibial
vein [2–5]. The lateral plantar veins are more affected by
thrombosis than the medial plantar veins are [4, 5].
Virchow proposed a triad to describe the potential
causes of venous thrombosis. This triad has been modified to the following factors: blood coagulability, changes
in the vessel wall (inflammation and friction) and stasis.
Various diseases, such as genetic disorders in the making
of coagulation factors or neoplastic syndromes, as well as
the intake of oral contraceptives, cause increased coagulability of blood [6].
In the literature, cases of plantar vein thrombosis have
been reported in patients with clotting diseases and paraneoplastic syndromes, after trauma or in postoperative states
(immobilization and after saphenectomy) [2–5]. To the best
Vansevenant and Vanhoenacker: Plantar Vein Thrombosis
99
Figure 1: Ultrasound of the left foot. Sagittal view (A). There is a normal thickness of the plantar fascia between 2 and 4 mm
(arrow). Tubular, hypoechoic structures are seen near the plantar fascia.Coronal view (B) with compression and color Doppler
imaging. These structures are not compressible, and there is no blood flow. The thrombus (arrow) is located deeply and m
­ edially
to the plantar artery (arrowhead) and between the musculus (m.) flexor digitorum brevis (1) and m. abductor hallucis (2). Sagittal
view with color Doppler imaging (C). The thrombi (B-C) are located deeply beneath the medial plantar artery (arrow).
Figure 2: MRI of the left foot. Coronal reformatted T2-WI FS (A) showing subtle intramuscular edema (arrow) adjacent to
the medial plantar veins. The thrombosed vein itself is not visible. Medially from the medial plantar artery and veins is
the m. abductor hallucis (1); laterally the m. flexor digitorum brevis (2); and deeply beneath is the m. quadratus plantae (3).
Sagittal reformatted T1-weighted subtraction image after gadolinium (B). There is a filling defect in the medial plantar
veins (arrows) with a thin sleeve of hyperintense contrast around the thrombus.
100
Figure 3: Position of the ultrasound probe for visualization of the medial plantar veins in a coronal plane. To
visualize the medial plantar veins in a sagittal plane,
the probe is turned 90° in a longitudinal ­direction on
the foot.
Vansevenant and Vanhoenacker: Plantar Vein Thrombosis
of our knowledge, there are no known cases of plantar vein
thrombosis resulting from wearing inappropriate footwear.
In our case, a possible explanation for the plantar vein thrombosis is venous stasis of blood and local trauma caused by the
hump on the inner sole of the shoe of the patient.
The preferred imaging modality for the diagnosis of
plantar vein thrombosis is ultrasound (Figure 3). The
presence of noncompressible veins, adjacent to the
medial or lateral plantar artery (which can be used as
an anatomical landmark), is the hallmark of the disease.
On color Doppler ultrasound, there is absence of venous
flow [2–5]. MRI is usually not required, but it can be
helpful in obese patients or patients with horny plantar
skin. In case of thrombosis, there is a filling defect on
T1-weighted images (WI) after administration of gadolinium contrast, and absence of hyperintense veins on
T2-WI. In normal conditions, the plantar veins are hyperintense on T2-WI, particularly if fat suppression is applied
(Figure 4). In addition, subtle perivascular edema in the
muscles adjacent to the plantar veins can be seen [2, 4].
Conclusion
Although relatively rare, plantar vein thrombosis should
be considered in the differential diagnostic list of plantar
pain, particularly in the appropriate clinical setting. Systematic and meticulous inspection of the plantar veins on
ultrasound and MRI is warranted to recognize this likely
underestimated disease.
Competing Interests
The authors declare that they have no competing interests.
Figure 4: MRI of the left foot in a normal patient for
comparison. Coronal reformatted T2-WI showing
clearly the hyperintense medial plantar veins (arrow)
in normal conditions. The veins are surrounded by the
m. abductor hallucis (1) medially; the m. quadratus
plantae (2) deeply from the veins; and the m. flexor
digitorum brevis (3) laterally. The muscle belly of the
m. abductor digiti minimi (4) is located at the lateral
plantar aspect of the foot.
References
1.
Thomas, JL, Christensen, JC, Kravitz, SR, et al.
The diagnosis and treatment of heel pain: A clinical
practice. J Foot Ankle Surg. 2010; 49: S1–S19. DOI:
http://dx.doi.org/10.1053/j.jfas.2010.01.001. PMid:
20439021.
2.
Siegal, DS, Wu, JS, Brennan, DD, Challies, T
and Hogman, MG. Plantar vein thrombosis: A rare
cause of plantar foot pain. Skeletal Radiol. 2008; 37:
267–269. DOI: http://dx.doi.org/10.1007/s00256007-0419-y. PMid: 18058094.
3.
Bernathova, M, Bein, E, Bendix, N and Bodner, G.
Sonographic diagnosis of plantar vein thrombosis. Report of 3 cases. J Ultrasound Med. 2005; 24:
101–103. PMid: 15615934.
4.
Cohen, M, Demondion, X and Iscain, P. Les
veines du pied. In: Morvan, G et al. (Eds.) Le pied –­
Monographie de la SIMS. Montpellier-Paris: Sauramps
Medical. 2011; pp. 271–281.
5.
Long, A, Bura-Riviere, A and Sapoval, M. Plantar
venous thrombosis and anticardiolipin antibody
syndrome. Case report. J Mal Vasc. 2004; 29(1):
39–40. DOI: http://dx.doi.org/10.1016/S03980499(04)96711-X
6.
Esmon, CT. Basic mechanisms and pathogenesis of
venous thrombosis. Blood Rev. 2009; 23: 225–229.
DOI: http://dx.doi.org/10.1016/j.blre.2009.07.002.
PMid: 19683659; PMCid: PMC2762278.
Vansevenant and Vanhoenacker: Plantar Vein Thrombosis
101
How to cite this article: Vansevenant, M and Vanhoenacker F M 2015 Plantar Vein Thrombosis: An Unusual Cause of Plantar Pain.
Journal of the Belgian Society of Radiology, 99(2), pp. 98–101, DOI: http://dx.doi.org/10.5334/jbr-btr.874
Published: 30 December 2015
Copyright: © 2015 The Author(s). This is an open-access article distributed under the terms of the Creative Commons
Attribution 3.0 Unported License (CC-BY 3.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original author and source are credited. See http://creativecommons.org/licenses/by/3.0/.
Journal of the Belgian Society of Radiology is a peer-reviewed open access journal
published by Ubiquity Press.
OPEN ACCESS